WSR 00-06-027

PERMANENT RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed February 24, 2000, 12:24 p.m. ]

Date of Adoption: February 24, 2000.

Purpose: To clarify rule language in WAC 296-23A-0200, 296-23A-0210, 296-23A-0220, and 296-23A-0240 without changing the intent of WAC 296-23A-0230.

Citation of Existing Rules Affected by this Order: Amending WAC 296-23A-0200, 296-23A-0210, 296-23A-0220, and 296-23A-0240.

Statutory Authority for Adoption: RCW 51.04.020, 51.04.030, 51.36.080.

Adopted under notice filed as WSR 99-37 [00-01-192] on December 22, 1999.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 4, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 4, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 4, Repealed 0. Effective Date of Rule: March 26, 2000.

February 24, 2000

Gary Moore

Director

OTS-3623.1


AMENDATORY SECTION(Amending WSR 97-06-066, filed 2/28/97, effective 4/1/97)

WAC 296-23A-0200
How does the department pay for hospital inpatient services?

The department will pay for hospital inpatient services according to the following table:


Hospital Type or Location Do Diagnosis Related Group (DRG) payment methods apply? Do per diem payment methods apply? Do percent of allowed charges (POAC) payment methods apply to hospital inpatient services?
Children's Hospitals No No Yes, paid 100% of allowed charges
Chronic Pain Management Program Exempt, paid per department agreement. Exempt, paid per department agreement. Exempt, paid per department agreement.
Health Maintenance Organizations No No Yes, paid 100% of allowed charges
Military No No Yes, paid 100% of allowed charges
Veterans Administration No No Yes, paid 100% of allowed charges
State psychiatric facility No No Yes, paid 100% of allowed charges
((Hospitals not in Oregon, Idaho or Washington No No Yes, paid 97% of allowed charges
Oregon and Idaho No No Yes, paid the Washington statewide average POAC factor))
Washington rural

(Peer Group A)

No Yes, statewide per diem rates apply for five DRG categories: Chemical dependency, psychiatric, rehabilitation, medical, and surgical DRGs No
All other Washington hospitals Yes Yes, state-wide average per diem rates apply for designated categories: Chemical dependency, psychiatric, rehabilitation, low volume medical, and low volume surgical DRGs Yes, applies to low cost outlier payments and high cost outlier payments above the high cost outlier threshold

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. 97-06-066, 296-23A-0200, filed 2/28/97, effective 4/1/97.]


AMENDATORY SECTION(Amending WSR 97-06-066, filed 2/28/97, effective 4/1/97)

WAC 296-23A-0210
How do self-insurers pay for hospital inpatient services?

Self-insurers will pay for hospital inpatient services using percent of allowed charges (POAC) factors, according to the following table:


Hospital Type or Location Do percent of allowed charges (POAC) payment methods apply to hospital inpatient services?
Military, Veteran's Administration, Health Maintenance Organizations, State Psychiatric Facilities, Children's Hospitals Yes, paid 100% of allowed charges
((Hospitals not in Oregon, Idaho or Washington Yes, paid 97% of allowed charges
Oregon and Idaho Yes, paid the Washington state-wide average POAC factor))
All other Washington hospitals Yes, paid the hospital specific POAC factor

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. 97-06-066, 296-23A-0210, filed 2/28/97, effective 4/1/97.]


AMENDATORY SECTION(Amending WSR 97-06-066, filed 2/28/97, effective 4/1/97)

WAC 296-23A-0220
How does the department or self-insurer pay for hospital outpatient services?

The department or self-insurer will pay for hospital outpatient services according to the following table:


Hospital Type or Location Do percent of allowed charges (POAC) payment methods apply? Does the department's Medical Aid Rules and Fee Schedules apply to hospital outpatient radiology, laboratory, pathology an physical therapy services?
Children's Hospitals Yes, paid 100% of allowed charges Yes
Chronic Pain Management Program Exempt, paid per department agreement Exempt, paid per department agreement
Health Maintenance Organizations Yes, paid 100% of allowed charges Yes
Military Yes, paid 100% of allowed charges No, paid 100% of allowed charges
Veterans Administration Yes, paid 100% of allowed charges No, paid 100% of allowed charges
State psychiatric facility Yes, paid 100% of allowed charges Yes
((Hospitals not in Oregon, Idaho or Washington Yes, paid 97% of allowed charges No, paid 100% of allowed charges
Oregon and Idaho Yes, paid the Washington statewide average POAC Yes))
Washington rural (Peer Group A) Yes, applies to hospital outpatient services except radiology, laboratory, pathology and physical therapy Yes
All other Washington hospitals Yes, applies to hospital outpatient services except radiology, laboratory, pathology and physical therapy Yes

Hospitals are reimbursed only for the technical component of rates listed in the fee schedules, for outpatient radiology, pathology and laboratory services.

See chapter 296-23 WAC for rules on radiology, pathology, laboratory, physical therapy and work hardening services.

See WAC 296-20-132 and 296-20-135 for information on the conversion factor used for hospital outpatient services.

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. 97-06-066, 296-23A-0220, filed 2/28/97, effective 4/1/97.]


AMENDATORY SECTION(Amending WSR 97-06-066, filed 2/28/97, effective 4/1/97)

WAC 296-23A-0240
How does the department define and pay a new hospital?

New hospitals are those open for less than one year prior to the implementation of the department's most recent hospital payment rates. The department will pay new hospitals according to the following table:


Hospital Type or Location What Diagnosis Related Group (DRG) base price applies? What Per Diem Payment Rates Apply? What percent of allowed charges (POAC) factor applies?
((Oregon and Idaho Exempt Exempt Washington state-wide average POAC
Hospitals not in Oregon, Idaho, or Washington Exempt Exempt Paid 97% of allowed charges))
Military, Veterans Administration, State Psychiatric, Health Maintenance Organization, Children's, Exempt Exempt Paid 100% of allowed charges
Chronic Pain Management Program Exempt, paid per department agreement Exempt, paid per department agreement Exempt, Paid per department agreement
Washington Rural Hospital

(Peer Group A)

Exempt Washington state-wide average per diem rates Washington state-wide average POAC
Other Washington Hospital Weighted median case-mix adjusted average cost per case for Washington DRG hospitals, except major teaching hospitals Washington state-wide average per diem rates Washington state-wide average POAC

A new hospital will be paid using its hospital-specific POAC within three years of receiving a provider account number(s) from the department.

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. 97-06-066, 296-23A-0240, filed 2/28/97, effective 4/1/97.]

Washington State Code Reviser's Office